1. health and fitness
2. disease

The Greater Risk?
SA
M
PL
E
Disease vs. Vaccine
Introduction
The Greater Risk? Disease vs. Vaccine is a set of quick reference
cards for immunization staff. The intention is to educate
healthcare personnel to accurately portray disease risk vs. vaccine
risk. The front of each card discusses the disease and the back
details the vaccine, offering an instant, factual comparison.
Hesitant parents don’t recognize the dangers of getting a vaccine
preventable disease. Sharing this additional information assists
them in making an informed decision.
The Greater Risk? Disease vs. Vaccine
The Vaccine Preventable Disease Community Program
Snohomish Health District in Everett, Washington.
3020 Rucker Avenue, Suite 208, Everett, WA 98201
www.snohd.org
© Snohomish Health District.
To request additional copies or for permission to re-use content, contact:
425.339.5234
The Greater Risk?
Disease vs. Vaccine
Table of Contents
• Safety Considerations in Vaccination
• Diphtheria
• Haemophilus influenzae Type B
• Hepatitis A
• Hepatitis B
• Human Papilloma Virus
• Influenza
• Measles
• Meningococcal Disease
• Mumps
• Pertussis
• Pneumococcal Disease
• Polio
• Rotavirus
• Rubella
• Tetanus
• Varicella
Safety Considerations in Vaccination
UNIVERSAL CONTRAINDICATION FOR ALL VACCINES: A severe
allergic (anaphylactic) reaction to a previous dose or a vaccine
ingredient. 2.
CONTRAINDICATION: A condition in a patient that greatly increases
the chance of a serious adverse reaction. A contraindication can be
permanent or temporary (i.e. pregnancy).
3.
PRECAUTION: A condition in a patient that might increase the chance of
a serious adverse event.
4.
FALSE CONTRAINDICATIONS: Mild illness; antibiotic therapy; disease
exposure or convalescence; pregnant or immunocompromised person
in the household; breastfeeding; preterm birth; allergy to products not
present in vaccine; allergy that is not anaphylactic; family history of
adverse events; Tuberculin skin test (affects the timing of a vaccine, but
doesn’t prevent it being given); multiple vaccines due at one visit.
5.
IMMUNE COMPROMISED INDIVIDUALS:
PL
M
LIVE VACCINES can cause severe or fatal reactions in
immunocompromised persons due to uncontrolled replication of the
vaccine virus. Examples of diseases causing immunosuppression:
Congenital immunodeficiency, leukemia, lymphoma, generalized
malignancy. Drugs causing immunosuppression: chemotherapy,
corticosteroids.
SA
E
1.
INACTIVATED VACCINES can be given if indicated. Hematopoietic
Cell Transplant: re-vaccinate with inactivated vaccines 6 months after
transplant.
6.
RECENT USE OF ANTIBODY CONTAINING BLOOD PRODUCTS may delay
some vaccines because the blood product antibodies may interfere with vaccine antibody production.
7.
Always consult package insert for specific manufacturer information. 8.
Always carefully screen a recipient for any contraindications or
precautions.
Diphtheria
Transmission
Respiratory tract droplets; cutaneous
diphtheria by contact with skin
lesions.
Incubation
2 to 5 days, range 1-10 days.
Symptoms
Low grade fever, sore throat, a
membrane in the nose or throat,
very swollen neck glands.
Contagious
Highly contagious.
M
PL
E
Agent
Toxin-producing
bacteria
Corynebacterium
diphtheria.
SA
Heart, kidney and neurological
problems because the toxin affects
protein production in all body cells.
Possible
complications Pneumonia, respiratory failure. Airway
can be blocked by a membrane
resulting in coma and death.
Disease risk
Severe disease is usually in the
unimmunized. Overall fatality rate is
5%-10% but up to 20% in children
under 5 and adults over 40.
Treatment
Anti-toxin and antibiotics; active
vaccination during convalescence.
Diphtheria
Vaccine(s)
Diphtheria in combination with tetanus
toxoid as DT (pediatric), as Td (adult),
with tetanus and pertussis as DTaP and
Tdap.
Appearance
After reconstitution and/or shaking,
combination vaccine is a white
cloudy liquid. Read package insert for
description and specific directions.
Dose/route
0.5ml IM.
Vaccine risk
Local reactions (redness, swelling, pain)
are common. An exaggerated local
(Arthus) reaction occurs occasionally. A
severe reaction may occur 1:1 million
doses administered. Fever, hives,
neurological complications are rare.
False
Contraindications
Minor illness, pregnancy,
immunosuppression.
Haemophilus
influenzae type b
disease (HIB)
Bacteria. Infection can occur in a variety of
sites: brain, lungs, heart, joints, blood stream,
bones, abdomen.
Transmission
Inhalation of respiratory tract droplets or
direct contact with respiratory tract secretions.
Incubation
Unknown.
Symptoms
The most severe symptoms occur when
bacteria enter bloodstream. Symptoms depend
on site affected (i.e. fever, irritability, stiff
neck with meningitis; life-threatening airway
obstruction with epiglottitis).
Contagious
Limited, but increased in household, child care
or institutional setting.
Possible
complications
Hearing impairment or neurological damage
(15% - 30% of survivors), serious breathing
problems. Death rate is 2%-5% regardless of
antibiotic therapy.
Disease risk
High risk populations: children up to age
5, older children and adults with anatomic
or functional asplenia, sickle cell disease,
immunodeficiency, chemotherapy, HIV
infection and recipients of a hematopoietic
stem cell transplant.
Treatment
Antibiotics and supportive care.
SA
M
PL
E
Agent
Haemophilus influenzae
type b disease (HIB)
Vaccine(s)
Both single antigen and combination
vaccines are conjugated. Not all
vaccines are interchangeable. Consult
package insert to verify vaccine dose #
and age are appropriate for patient.
Appearance
Generally, the vaccine is a clear to
whitish suspension. Consult package
insert for description and other specific
information.
Dose/route
0.5ml IM.
Vaccine risk
Swelling, redness, pain at the injection
site have been reported by 5%-30%
of recipients and usually resolve within
12-24 hours. No known association
between HIB vaccine and any serious
adverse events.
Contraindications
To preserve immunological response to
later vaccines, infants under 6 weeks
should not be immunized.
False
Contraindication
Minor illness.
Hepatitis A
RNA virus of the
picornavirus group.
Transmission
Most commonly
fecal-oral; can be
by personal contact,
contaminated food
or water.
Incubation
15 to 50 days, average of 28 days.
Symptoms
Fever, malaise, jaundice, loss of appetite, nausea.
Contagious
Symptomatic infection occurs in up to 30% of
children under 6; very few have jaundice. In older
children and adults, jaundice occurs in 70% of
the cases; symptoms last less than 2 months but
10%-15% have prolonged or relapsing disease for
as long as 6 months.
Possible
complications
Death from severe hepatitis A is more common in
people with underlying liver disease. About 100
people die of Hep A annually in the U.S. Adult
hospitalization rates are 11%-22%. Average work
loss is 27 days. Adults over 40 are at higher risk
for serious outcomes.
SA
M
PL
E
Agent
Disease risk
Increased risk: international travel, household
or personal contact with a child attending a child
care facility during a food-borne outbreak, men
who have sex with men, and illegal drug users.
Treatment
Supportive measures. Immune globulin IM within
2 weeks post-exposure or pre-exposure to protect
infants under12 months traveling out of country.
Infants over 12 months, older children and adults
under 40: give dose #1. Adults over 40 should
initially receive both IG and dose #1 of vaccine.
Hepatitis A
Vaccine(s)
Inactivated whole-virus vaccine. Two
brands are interchangeable and have a
pediatric and an adult version. Available
in single antigen or combination A/B
vaccine for adults needing both.
Appearance
Generally, all brands are a cloudy white
suspension. Consult package insert for
manufacturer’s description and other
specific information.
Dose/route
0.5ml IM.
Vaccine risk
Mild and self-limited local reaction
reported by 20%-50% of recipients. Up
to 10% complain of malaise, fatigue,
low-grade fever. No known severe
reactions have been related to vaccine.
False
Contraindications
Pregnancy, immunocompromised status.
Hepatitis B
Transmission
Infected blood or body fluids (serum, semen,
saliva). Commonly via contaminated needles or
syringes; sexual contact with infected persons;
during birth for infants of infected mothers.
Incubation
45 to 160 days, average of 90 days.
Contagious
M
PL
Symptoms
E
Agent
Hepadnaviridae virus.
Remains infectious on
environmental surfaces
for more than 7 days at
room temperature.
Infants and children under 5 have milder acute
illness than older children and adults. Symptoms
vary from loss of appetite, nausea, pain in joints,
malaise to jaundice and severe hepatitis.
About 2 billion worldwide have been infected,
and more than 350 million have lifelong chronic
infection; many do not know they are chronically
infected.
Virus causes acute and chronic hepatitis, scarring
of the liver and up to 80% of liver cancer. A
person becomes chronically infected when acute
infection does not clear, leading to lifetime
contagion.
Disease risk
About 25% of chronically infected people die
prematurely of liver cancer; their risk is 300 times
greater than those not chronically infected. When
a pregnant woman acquires HBV infection, it can
cause severe disease in the mother and chronic
infection in the fetus.
Treatment
Supportive care; interferon.
SA
Possible
complications
Hepatitis B
Vaccine(s)
Two single antigen recombinant
vaccines with adult and pediatric
versions; two combination vaccines:
DTaP + IPV + HepB and HepA + HepB.
Appearance
General appearance is a cloudy, white
suspension. Consult package insert for
description and specific information.
Dose/route
0.5ml or 1.0ml IM; depends on vaccine,
age, risk factors.
Vaccine risk
Mild local reaction and minimal systemic
complaints of fatigue, headache,
irritability reported in up to 20%.
Severe reaction occurs about 1:1
million doses given.
Precaution
Immunocompromised people can be
vaccinated, but response may not be
optimal.
False
Contraindication
Pregnancy.
Considerations
At least 90% of newborns of infected
moms will develop chronic infection.
Between age 1 and 5 years 25%-50%
develop chronic infection. Only 2%-6%
of older children and adults become
chronically infected.
(HPV)
Human Papillomavirus
Transmission
Close contact, primarily sexual contact; rarely to a
newborn through the birth canal at delivery, or from
non-genital sites.
Incubation
Unknown, but estimated to range from 3 months to
several years; occasionally as long as 10 years
Symptoms
Most infections are painless and clear spontaneously;
when infection persists, it is the primary risk factor
for developing abnormal cells and cancers including
cervical, anal, vaginal, vulvar, penile, and some head
and neck cancers. It may take more than a decade for
abnormal cells to become cancerous.
PL
M
Incidence of infection is 40% by 24 months after first
sexual intercourse. More than 80% of sexually-active
women are infected by age 50. Men get and transmit
genital warts and can develop cancers.
SA
Contagious
E
Agent
Forty types of human
papillomaviruses (HPV)
can infect the genital
tract. Types 16, 18, 31
and 45 are most
associated with cancer;
many others cause
genital warts.
Possible
complications
HPV is thought to be responsible for 70% of cervical
cancer, 90% of anal cancer, 40% of vulvar, vaginal,
or penile cancers and 12% of oral and pharyngeal
cancers.
Disease risk
About 12,000 new cervical cancer cases and about
4,000 deaths in the U.S. annually. Numbers much
higher worldwide in countries where women do not
have regular Pap smears.
Treatment
Vaccination is key in the prevention of cervical cancer.
Regular Pap testing is still indicated. A variety of
treatments used to eliminate the lesions.
Human Papillomavirus (HPV)
Vaccine(s)
Vaccines use recombinant DNA technology.
One is bivalent (HPV2) and one is
quadrivalent (HPV4). Both vaccines are
licensed for females 9-26. Males 9-26
receive only the HPV4 vaccine to protect
against genital warts and cancer.
Appearance
Both vaccines are cloudy, white liquids.
Consult package insert for description and
specific instructions.
Dose/route
0.5ml IM.
Vaccine risk
Mild local reactions reported 20%-90% of
the time. A fever of 100 degrees in the 15
days following either vaccine was reported
by 10%-13% of recipients. Fainting
has been reported by adolescents who
received additional vaccines at same visit;
observe for 15 minutes following vaccine.
No serious adverse events have been
proven related to HPV vaccine.
Contraindication
Although not associated with any adverse
pregnancy outcomes, should be delayed
until after delivery.
Precaution
Immunosuppressed females can be
vaccinated, but vaccine efficacy may be
less.
False
Contraindications
Mild illness, breastfeeding.
Consideration
The catch up schedule uses the same
intervals as the routine recommendation.
Seattle policemen in masks during
influenza epidemic, Dec 1918
Influenza
(the ‘flu’)
Transmission
Person-to-person via respiratory droplets
created by coughing or sneezing.
Incubation
1 to 4 days, with an average of 2 days.
Symptoms
Sudden onset of fever accompanied by chills,
headache, malaise, muscle aches, mild
cough; next sore throat, nasal congestion,
runny nose, worsening cough. Less common
are bloodshot eyes, abdominal pain, nausea,
vomiting, diarrhea.
SA
M
PL
E
Agent
Virus of the
orthomyxovirus
family. The viruses
are separated into
groups A, B or C.
Contagious
Highly contagious. Highest attack rates occur
among school-age children who spread flu
secondarily to siblings and adults.
Possible
complications
Pneumonia (secondary bacterial) is the most
common complication. Other complications
include Reye’s syndrome, inflammation of
heart muscle, death.
Disease risk
Majority of deaths occur in persons 65 and
older (90%), young children, those with
underlying medical conditions. Hospitalization
rates of children birth to 4 are similar to
persons 65 years of age or older.
Treatment
Supportive care, antiviral medications,
antibiotics for secondary bacterial infections.
Influenza (the ‘flu’)
Vaccine(s)
Recommended annually for everyone 6 months
or older. All vaccines are multi-valent and contain
group A and group B strains. The C group is mild and
infrequent so is not in the vaccine. There are several
versions of vaccine: injectable inactivated (TIV), high
dose inactivated injectable (TIV), intradermal, live
attenuated nasal mist (LAIV).
Appearance
Vaccine appearance varies with the brand. Consult
package insert for description and other specific
information.
Dose/route
TIV dose 0.25 ml or 0.5 ml IM; Intradermal 0.1 ml IM
with a micro injector; nasal mist 0.2 ml divided with
0.1 ml sprayed into each nostril.
Vaccine risk
TIV: local reaction (15%-20%). Fever and malaise
uncommon; allergic reactions rare; neurological
reactions very rare. LAIV: runny nose and headache
(10%-40%). Intradermal: no serious adverse
reactions have been identified.
Contraindications
LAIV: Asthma, a recent wheezing episode, reactive
airway disease or other chronic pulmonary or heart
condition, metabolic disease such as diabetes, kidney
disease or abnormal hemoglobin, such as sickle cell
disease, children and adolescents receiving long-term
aspirin therapy, immunosuppression, pregnancy,
history of severe allergy to egg, severe illness or nasal
congestion.
Precautions
LAIV: History of Guillian Barre’ syndrome within 6
weeks of a previous dose; do not give until 48 hours
after stopping anti-viral therapy; do not administer
anti-viral medications for 2 weeks after receipt of LAIV.
TIV and Intradermal: History of Guillian Barre’
syndrome within 6 weeks of a previous dose.
False Contraindications
TIV and Intradermal: Pregnancy, breastfeeding,
immunosuppressed status.
Measles
A paramyxovirus.
Transmission
Primarily person-to-person
via large respiratory
droplets. Airborne transmission via virus containing
droplets in the air for up to
2 hours after a contagious
patient leaves a room.
Incubation
From exposure to first symptoms 10 to 12 days; fever
increases over 2-4 days, peaking as high as 103 to 105
degrees F; Koplik spots from 1-2 days before to 1-2
days after the rash.
Symptoms
Fever, cough, runny nose, redness of the eyes,
generalized, raised, red rash.
Contagious
Highly contagious with an attack rate >90% among
susceptible persons. Maximum communicability is
from onset of early symptoms to the first 3-4 days of
the rash.
M
PL
E
Agent
Disease risk
Sub acute sclerosing panencephalitis (SSPE) is a
rare degenerative disease thought to be caused by
persistent measles infection in the brain. Onset is
about 7-10 years after the measles and it causes
progressive deterioration of behavior and intellect,
inability to control voluntary muscles, seizures and
eventual death. It occurs in 5–10 cases per million
reported cases.
Treatment
Supportive care.
SA
Possible
complications
Complications occur in 30% of cases and are more
common in children under 5 and adults 20 and older.
Pneumonia is the most common cause of death (60%)
in children. Acute encephalitis is most common in
adults with a death rate of 15%. Lasting neurological
damage present in 25%; death is reported in 0.2% of
the cases in the U.S.
Measles
Vaccine(s)
Live attenuated vaccine in combination with
mumps and rubella (MMR) and with mumps,
rubella, and varicella (MMRV). Vaccination is not
contraindicated when given within 72 hours of
exposure. Immune globulin within 6 days may
prevent or decrease the severity of measles.
Appearance
Lyophilized powder turns to a clear yellow liquid
when reconstituted.
Dose/route
0.5ml SC.
Vaccine risk
About 5% have transient rash. Fever > 103
degrees F without other symptoms 6-12 days
after vaccination is reported 5%-15%. Children
with history of febrile seizures may have seizures.
Temporary low platelets occur in from 1:25,000 to
1:2,000,000 doses administered. Central nervous
system conditions such as encephalitis occur in
less than 1:1,000,000 doses administered.
Contraindications
Children with egg allergy are at extremely
low risk of a severe allergic reaction.
Contraindications: Pregnancy or becoming
pregnant within 4 weeks after vaccination.
Precautions
Those who have recently received blood products
containing antibodies need to delay vaccination to
avoid interference with immune response; those
with history of low platelets need to weigh the
benefits versus the risk.
False Contraindications
Close contact with pregnant woman,
breastfeeding.
Considerations
About 49% of deaths are among children younger
than 5. Ninety percent of fatal cases occur in
those without history of immunization. Blacks
and Hispanics are at higher risk than white nonHispanics.
Meningococcal
Transmission
Droplets of bacteria-containing mucus or
secretions from the nose and throat of colonized
persons; person-to-person, close contact in
crowded conditions (i.e. college dorms or military
barracks) required for spread.
Incubation
3-4 days, range of 2 to 10 days.
Symptoms
Most common form is meningitis: rapid
onset fever, headache, stiff neck, sometimes
accompanied by nausea, vomiting, sensitivity to
light, altered mental status. Bloodstream infection
occurs without meningitis 5%-20% of the time:
fever, a red/purple rash, often accompanied by low
blood pressure, shock, acute adrenal hemorrhage,
multi-organ failure. Least common forms are
pneumonia (5% to 15% of cases), arthritis (2%),
epiglottitis (1%).
SA
M
PL
E
Agent
Bacterium Neisseria
meningitidis; strains
A, B, C, Y, and
W-135 cause almost
all invasive disease.
Contagious
In households, only 3%-4% had secondary cases
and most had one case. This translates into 2-4
cases per 1,000. However, that is 500-800 times
the risk in the general population.
Possible
complications
The case fatality rate of invasive disease is 9%12%; and up to 40% for meningococcemia.
Disease risk
Up to 20% of survivors have permanent
conditions, such as hearing loss, neurological
damage or amputation of finger(s) or limb(s).
Treatment
Antibiotics; management of shock and increased
intracranial pressure.
Meningococcal
Vaccine(s)
Quadrivalent polysaccharide (MPSV4);
quadrivalent conjugate (MCV4). Those with
ongoing risk (i.e. microbiologists, military
recruits, travelers) should be vaccinated every
5 years. If 1st dose MPSV4 or MCV4 at age
2 – 6 years, vaccinate 3 years later. If the 1st
dose > 7 years of age, vaccinate 5 years later.
People with persistent complement deficiency
and functional or anatomical asplenia should
receive a 2-dose primary series given 2
months apart and booster every 5 years.
Appearance
MPSV4 is a clear, colorless liquid after
reconstitution. For MCV4 vaccines, consult
package insert for description and specific
information.
Dose/route
MPSV4 0.5ml SC; MCV4 vaccines 0.5mlIM.
Vaccine risk
MPS4: local reaction (48%), fever up to 3%,
malaise and headache within 7 days are
reported up to 60% of the time, but only 3%
were reported as severe. MCV4 reactions:
similar to MPSV4.
Precautions
If moderately or severely acutely ill,
delay until improved. There have been no
documented adverse events among pregnant
women or newborns (MPSV); there is no data
for MCV4.
False Contraindications
Pregnancy, breastfeeding,
immunosuppression.
Considerations
People with deficiencies in the terminal
common complement pathway, functional or
anatomic asplenia and HIV are high risk for
disease.
Mumps
A paramyxovirus.
Transmission
Contact with infected
respiratory tract secretions.
Incubation
14 to 18 days
(range 14 to 25 days).
Symptoms
Early symptoms: muscle aches, loss of appetite,
malaise, headache, low grade fever. Parotitis
(swelling of the parotid and other salivary glands)
is the most common sign (30%-40%) and occurs
within the first 2 days and resolves after 10
days. About one third of infections do not cause
swollen glands and appear to be a respiratory tract
infection.
Contagious
Contagious from 3 days before to the fourth day of
active disease.
SA
M
PL
E
Agent
Possible
complications
Symptomatic meningitis (headache and stiff neck)
occur in 15% and usually resolves completely.
Bilateral testicular inflammation affects about
30% of post-pubertal males, with about 50%
having some degree of testicular atrophy, although
sterility is rare. Post-pubertal females (5%) may
experience ovarian inflammation. Asymptomatic
septic meningitis occurs in 50%-60% of cases.
Disease risk
The least common complications are pancreatitis,
joint pain, and kidney inflammation. Deafness
occurs in 1: 20,000 reported cases; it is one
sided (80%), of sudden onset and permanent.
Inflammation of heart muscle with EKG changes
is seen in 3%-15%, but usually with complete
recovery.
Treatment
Supportive. Mumps vaccine has not shown to be
effective in preventing mumps after exposure.
Mumps
Vaccine(s)
Live-attenuated mumps vaccine is combined
with measles and rubella (MMR) and with
measles, rubella, and varicella (MMRV).
Appearance
Once reconstituted, MMR is a yellow clear
liquid.
Dose/route
0.5 ml SC.
Vaccine risk
Reactions to MMR are more likely related
to the measles or rubella portions of the
vaccine (i.e. fever, rash, and joint pain).
Severe reactions to the vaccine are very
rare.
Contraindications
Pregnancy, moderate to severe acute illness
and immunocompromise due to disease or
medication.
Precautions
Low-dose alternate-day topical or
aerosolized steroid preparations or persons
who have discontinued steroid therapy for
one month or chemotherapy for 3 months
can be vaccinated; recent treatment with
a blood product may delay vaccination.
Most anaphylactic reactions to MMR are not
related to egg allergy, but to some other
vaccine components, such as gelatin.
Considerations
Adults are more likely to have severe
disease and die from mumps or its
complications. Women in the first trimester
of pregnancy who contract mumps have
increased risk of spontaneous abortion.
Pregnancy should be avoided for 28 days
after mumps immunization.
Pertussis
(Whooping
Cough)
Toxin-producing bacterium
Bordetella pertussis.
Transmission
Close contact with cases via
aerosolized droplets. Neither
infection nor immunization
provides lifelong immunity.
Incubation
7 to 10 days, with a range
of 5 to 21 days.
Symptoms
There are three stages of pertussis. The catarrhal stage is
characterized by runny nose, sneezing, low grade fever,
cough that becomes increasingly severe for 1-2 weeks.
The paroxysmal stage is characterized by bursts of rapid
coughing with a long inspiration (the ‘whoop’ heard in older
children and adults) but the cough does not effectively
remove the thick mucus; infants and young children appear
very ill, distressed and bluish, some even stop breathing;
vomiting mucus after coughing exhausts them; this stage
can last up to ten weeks. The convalescent stage is when
symptoms gradually resolve over many more weeks;
paroxysms often recur with URIs for many months.
SA
M
PL
E
Agent
Contagious
As many as 80% of immunized household contacts of a
symptomatic case acquire infection due to waning immunity
of vaccine. Older siblings, adolescents and adults with mild
or asymptomatic disease expose infants.
Possible
complications
Less serious complications include ear infection, loss of
appetite, and dehydration. Adolescents and adults may have
difficulty sleeping, urinary stress incontinence, or even rib
fractures from the violent coughing. The increased pressure
of severe paroxysms can result in a collapsed lung, bloody
nose, subdural hematomas, hernias, rectal prolapse.
Disease risk
Those at highest risk of serious complication or death are
infants under 6 month. The most common complication is
bacterial pneumonia (1 in 20). Neurological complications
are more common in infants. One in eighty has seizures or
some other neurological issue.
Treatment
Supportive care; antibiotics for close contacts to prevent
disease.
Pertussis
(Whooping Cough)
Vaccine(s)
Subunit vaccines contain multiple, purified and
inactivated components of B.pertussis cells and vary
by manufacturer. Clinical judgment or an outbreak
in the community can affect recommendations.
A woman who becomes pregnant should receive
one Tdap dose either after 20 weeks gestation or
immediately postpartum. There is no minimum
interval between Tdap and the last tetanus
containing vaccine.
Appearance
A slightly cloudy suspension. Check package insert
for description and specific information.
Dose/route
0.5ml IM.
Vaccine risk
DTaP: High fever is reported by 3%-5%; prolonged
crying for 3 or more hours reported 1:1,000
doses; local reaction reported by 20%-40%.
Severe reactions occur in about 1:1,000,000 doses
administered. Tdap: Fever reported in 1.4%, local
reaction 21%-66%. Other adverse reactions include
GI symptoms, headache, fatigue. No serious adverse
reactions have been proven to be caused by Tdap.
Contraindications
DTaP: Encephalopathy not due to another
identifiable cause within 7 days of vaccination and
moderate or severe acute illness.
Tdap: Encephalopathy as above.
Precautions
DTaP: Fever of 105 degrees F within 48 hours,
not due to another identified cause; collapse or
shock like state; inconsolable crying for more
than 3 hours; convulsions with or without fever
occurring within 3 days. Tdap: History of Guillain
Barre’ syndrome within 6 weeks of a previous dose;
moderate or severe acute illness; history of a severe
local reaction following a prior dose of a vaccine
containing tetanus and/or diphtheria toxoids.
Pneumococcal
Transmission
Person-to-person via respiratory droplet contact; people who
are colonized (have the bacteria in their respiratory tract but
have no symptoms) may develop active infection.
Incubation
Varies with the site of infection, as short as 1-3 days.
Symptoms
Pneumonia: abrupt onset of fever, chills, pleuritic chest
pain, purulent productive cough, shortness of breath, rapid
breathing, poor oxygenation, rapid heart rate, malaise,
weakness. Meningitis: stiff neck, fever, altered mental
status. Depending on the site of infection: ear pain, chest
pain, pus in the eyes.
SA
M
PL
E
Agent
Streptococcus pneumoniae
bacterium causes various
infections: sepsis, meningitis,
acute ear infections, sinusitis,
community-acquired
pneumonia, pleurisy, eye
infections.
Contagious
An estimated 5%-70% of healthy adults, and 21%-59% of
children are colonized (have the bacteria in their respiratory
tract but don’t appear ill) and are contagious to others.
Possible
complications
There are 3,000 to 6,000 cases of pneumococcal meningitis
a year. The bacteria are found in 28%-55% of middle ear
aspirants. Pneumococcal pneumonia causes about 175,000
hospitalizations annually. Complications include: infection
of the pleural space, inflammation of the heart muscle,
bronchial obstruction with collapse of the lung, formation
of a lung abscess. Bacteremia is most common in children,
50,000 cases annually.
Disease risk
People at highest risk: decreased immune function,
anatomic or functional asplenia, chronic heart, lung, liver,
or kidney disease, CSF leak, and cigarette smokers. Fatality
rate of pneumonia is 5%-7%, but much higher in the elderly.
Fatality rate of bacteremia is about 20%, but it can be as
high as 60% in the elderly. Death rate for pneumococcal
meningitis is about 30%, but as high as 80% in the elderly.
Treatment
Antibiotics and supportive care.
Pneumococcal
Vaccine(s)
A polysaccharide (PPSV23) and
a conjugate vaccine (PCV13)
are available, each with its own
recommendations.
Appearance
After vigorous shaking, PCV13 is a
homogenous, white suspension. Do not
use if it does not resuspend. PPSV23
is clear and colorless. Consult package
insert for specific information.
Dose/route
PCV 13 0.5ml IM; PPSV 0.5ml SC.
Vaccine risk
PPSV23: 30%-50% report a local
reaction. PCV13: <1% have a high
fever; up to 50% complain of local
reactions and about 8% are considered
to be severe (i.e. pain that interferes
with limb movement). Localized
reactions are more common with the
4th dose and include fever within 7 days
(24%-35%). Generalized symptoms:
poor appetite and irritability reported by
up to 80% of recipients. There are no
known serious adverse events caused
by either vaccine.
Contraindication
The safety of PPSV23 has not been
studied in pregnant women.
Polio
A Picornaviridae virus. There are three
strains (P1, P2, and P3) and immunity to
one strain does not produce significant
immunity to the others.
Transmission
Fecal-oral and respiratory routes. Before
and after illness onset, the virus is found
in the throat (for about 1 week) and is
shed in feces for several weeks.
Incubation
Asymptomatic or nonparalytic poliomyelitis 3 to 6 days;
paralytic polio 7-21 days.
Symptoms
Up to 95% of all polio infections are asymptomatic but
the virus is still transmitted to others. About 4%-8% of
polio cases consist of a minor, non-specific illness with no
evidence of central nervous system involvement. This is
called abortive poliomyelitis and the recovery is less than
a week. Minor symptoms are often followed by diminished
deep tendon reflexes, severe muscle aches, spasms in the
limbs or back. After days or weeks, strength returns, but is
asymmetrical. Many persons recover completely and muscle
function returns to some degree. Weakness or paralysis still
present after 12 months is usually permanent. Less than 1%
of cases result in paralysis.
M
PL
E
Agent
Poliovirus is highly infectious, for the susceptible household
contacts it is nearly 100% for children and 90% of adults.
Possible
complications
There are three types of paralytic polio: bulbar, spinal, and
bulbarspinal. Bulbar is uncommon and leads to weakness
of muscles innervated by the cranial nerves. Spinal is most
common and leads to asymmetrical paralysis of the legs.
Bulbarspinal is a combination of the two and is the next
most common after spinal.
Disease risk
Death rate for paralytic polio is 2%-5% among children and
up to 15%-30% among adults. It increases to 25%-75%
with bulbar involvement. Adults who contracted paralytic
polio during childhood may develop the noninfectious postpolio syndrome 30-40 years later, which is characterized
by slow but significant onset of muscle pain and increasing
weakness.
Treatment
Supportive care.
SA
Contagious
Polio
Vaccine(s)
Inactivated polio vaccine (IPV) is the
only vaccine available in the U.S. It
contains all 3 strains and is available
in multi-dose vials. There are three
combination vaccines: DTaP + IPV +
Hib; DTaP + IPV + Hep B, DTaP + IPV.
Consult package insert of combination
vaccines to determine appropriate
age(s) and dose(s).
Appearance
IPV is a clear, colorless liquid.
Dose/route
The dose is 0.5 ml SC or IM.
Vaccine risk
No serious adverse reactions to IPV are
documented. Mild local reaction can
occur.
Contraindications
IPV contains trace amounts of
streptomycin, neomycin, and polymixin
B, but if the allergy is only a local skin
reaction, vaccinate as indicated.
Precaution
Moderate or severe acute illness.
False Contraindications
Breastfeeding, an infant with diarrhea,
a minor URI with or without fever,
moderate local reaction to a previous
dose, current antibiotic therapy, and
recovering from an acute illness.
Considerations
Although considered eradicated in the
U.S., vulnerable travelers can contract
it, bring it back and infect others.
Rotavirus
Transmission
Oral-fecal route, close contact or indirect contact with
infected persons.
Incubation
Usually less than 48 hours.
Symptoms
The first infection is usually the most severe. Infection
may be asymptomatic, cause self-limited watery
diarrhea or may result in severe dehydrating diarrhea
with fever and vomiting. Up to 33% have a fever >102
degrees F. Gastrointestinal symptoms last 3 to 7
days.
PL
M
Highly contagious with nearly universal infection by
age 5. Spreads easily within families, institutions,
hospitals and child care settings. The virus can be
found on toys and hard surfaces.
SA
Contagious
E
Agent
RNA virus from the family
Reoviridae; can remain
viable on surfaces in the
environment for weeks or
months unless the surface
is disinfected. Most
common cause of severe
diarrhea requiring health
care in children.
Possible
complications
Infection can lead to severe diarrhea, dehydration,
electrolyte imbalance, metabolic acidosis. Children
who are immunocompromised by congenital
immunodeficiency, by solid organ or bone marrow
transplants may experience severe or prolonged
gastroenteritis and have evidence of abnormalities in
multiple organ systems, particularly the kidney and
liver.
Disease risk
Rotavirus infection accounts for 2.5% of all
hospitalizations of children. About 20% of adult
household contacts will develop symptomatic infection.
Treatment
Oral or IV fluids, and supportive care.
Rotavirus
Vaccine(s)
RV1 is a live attenuated vaccine containing
one strain of human rotavirus. RV5 has
five reassortment rotaviruses. First dose at
least 6 weeks but not later than 14 weeks,
6 days. Last dose no later than 8 calendar
months, 0 days.
Appearance
RV1 is a clear colorless fluid; RV5 is pale,
clear yellow liquid and may have a pink tint.
Dose/route
Both are given orally, before any injections,
so the infant is less upset. If an infant
vomits the vaccine, do not repeat the dose.
Vaccine risk
Adverse events noted in clinical trials include
vomiting (15%-18%), diarrhea (9%-24%),
irritability (13%-62%), fever (40% -43%).
However the rate of these complaints is the
same as unvaccinated infants.
Contraindications
Severe latex allergy (RV1 has latex
in the oral applicator), a history of
intussusceptions, severe combined
immunodeficiency disease (SCID).
Precautions
Altered immune competence; acute,
moderate or severe gastroenteritis; other
acute, moderate or severe illness; children
who are immunocompromised require
clinical judgment weighing risk versus
benefit; infants with HIV may be immunized
due to the considerably attenuated vaccine
strains versus wild.
False Contraindication
Breastfeeding.
Rubella
(German Measles)
Rubivirus.
Transmission
Direct or droplet contact with
nose and throat secretions. Up
to 50% of infections are asymptomatic. Crosses the placenta
during pregnancy causing birth
defects and Congenital Rubella
Syndrome (CRS).
Incubation
14 days, range of 12 to 23 days.
Symptoms
In children, rash is usually the first sign and a prodrome
(early warning signs) is rare. Older children and adults
have a 1 to 5 day prodrome with low-grade fever, malaise,
swollen lymph glands, and upper respiratory infection before
the rash. The rash begins on the face and then progresses
head to foot. It lasts about 3 days and may itch.
Contagious
Most contagious when the rash first appears. Virus may shed
from 7 days before to 5-7 days or more after the rash onset.
Possible
complications
Complications generally occur more often in adults than
children.
M
PL
E
Agent
Treatment
Supportive care.
SA
Disease risk
Rubella in a pregnant woman can cause fetal death,
spontaneous abortion, premature delivery. Congenital
Rubella Syndrome (CRS) occurs up to 80% of the time
causing a variety of birth defects: deafness, eye defects
(cataracts, glaucoma, retinopathy and abnormally small
eyes), heart defects, neurological abnormalities, small head,
mental retardation, bone lesions, spleen enlargement,
hepatitis, low platelets. Other complications: encephalitis
occurs in 1:6,000 cases and death estimates are up to 50%;
hemorrhagic symptoms occur in 1:3,000, more often in
children; gastrointestinal, cerebral, or kidney hemorrhages.
A rare, late complication is a progressive inflammation of the
white and gray matter of the brain. Sometimes symptoms
can be delayed from 2 to 4 years, as in the development
of diabetes. Up to 70% of adult women have joint pain and
inflammation, but they rarely become chronic.
Rubella (German Measles)
Vaccine(s)
Live attenuated vaccine available in MMR
and MMRV. Those born before 1957 are
considered immune. Health care workers
and pregnant women are held to a stricter
standard and must have either laboratory
proof of immunity or 2 valid doses of
a rubella containing vaccine. Clinical
diagnosis is unreliable and should not be
considered in assessing immune status.
Appearance
The vaccine is a clear yellow liquid after
reconstitution.
Dose/route
0.5ml SC.
Vaccine risk
Post vaccination complaints of fever and
rash are usually related to the measles
component of the vaccine. In about 25%
of female adolescents and female adults,
joint inflammation and pain can follow,
lasting 1-3 weeks and fully resolving.
Severe allergic reactions to the vaccine
are rare.
Contraindications
Pregnancy or becoming pregnant within 4
weeks after vaccination, immunodeficiency
resulting from leukemia, lymphoma,
generalized malignancy, immune
deficiency disease or immunosuppressive
therapy.
Precautions
Those using an alternate day topical or
aerosolized steroid preparation, steroid
therapy discontinued for 1 month or
chemotherapy for 3 months can be
immunized, delay vaccination until a
moderate or severe illness is improved.
Tetanus
(Lock Jaw)
Transmission
Spores are widely distributed in soil and in the feces of many
animals. Bacteria enter the body via a wound. In the low oxygen
conditions, spores germinate and produce toxin which spreads
through the blood stream and lymphatic system.
Incubation
3-21 days. The shorter the incubation period, the higher the
chance of death.
Symptoms
In local tetanus muscle contraction is in the same area as
the wound. Contractions persist for weeks and may precede
generalized tetanus. Only about 1% of cases are fatal. Cephalic
tetanus is a rare type that occasionally occurs with otitis media
or following a head injury; there is involvement of the cranial
nerves, especially in the face. Generalized tetanus is the most
common type (80%); lock jaw is followed by a stiff neck, difficulty
in swallowing, and rigidity of abdominal muscles; additional
symptoms are fever, sweating, elevated blood pressure, episodic
rapid heart rate; spasms occur frequently, last several minutes,
and continue for 3-4 weeks; complete recovery may take months;
fatality rate is about 11%. Neonatal tetanus occurs in infants born
without protective passive immunity from the mother because she
is inadequately immunized for tetanus; worldwide it kills more
than 257,000 infants annually.
SA
M
PL
E
Agent
An exotoxin produced
by the bacterium
Clostridium tetani;
the bacteria produce
spores that can
survive autoclaving
and chemical agents.
Contagious
Tetanus is the only vaccine-preventable disease that is not spread
person-to-person. Tetanus disease does not result in immunity
Possible
complications
Spasms of the vocal cords and/or spasms of the muscles of
respiration can compromise breathing. Secondary infections
may include sepsis from indwelling catheters, hospital-acquired
pneumonias, and bed sores.
Disease risk
Pulmonary embolism is a particular problem for the elderly
and illegal drug users. Aspiration pneumonia is a common late
complication (present in 50%-70% of autopsied cases).
Treatment
Support measures for an adequate airway. Tetanus Immune
Globulin (TIG) helps remove unbound toxin. Once stable, actively
immunize.
Tetanus
(Lock Jaw)
Vaccine(s)
Tetanus toxoid is available as a single
antigen as well as in combination with
other antigens: DTaP; DT (pediatric use);
Td; Tdap (adult use).
Appearance
The vaccine is a white homogenous cloudy
suspension.
Dose/route
0.5ml IM.
Vaccine risk
Injection site reactions are common;
a nodule at the injection site may take
weeks to resolve. Systemic symptoms
(i.e. fever) are uncommon. Exaggerated
local (Arthus-like) reactions (painful
swelling from shoulder to elbow) are
reported after receiving a dose of a
diphtheria-tetanus vaccine, usually in
adults who have received excessive doses
of tetanus toxoid.
Contraindications
If a contraindication exists for a multiantigen vaccine, TIG should be considered
for serious injuries. Moderate or severe
illness is also a contraindication.
Considerations
Immunization is critical. Major, dirty
wounds should be treated with both
TIG and tetanus toxoids. Persons with
uncertain immunization history or
incomplete primary series need TIG for
immediate passive immunity and a tetanus
vaccine for priming their immune system
so that they have the most benefit from
completing their primary series.
Varicella
(chickenpox)
A virus of the herpes family.
Transmission
The virus comes in contact with the
respiratory tract or the conjunctiva.
Person-to-person requires direct
contact, airborne droplets, infected
respiratory secretions, or contact
with shingles lesions.
Incubation
14-16 days and range 10-21 days.
Symptoms
A generalized, itchy, blistery rash; lesions are in varying
stages of development and resolution (crusting), mild
fever, malaise. Reactivation of the virus years later
results in shingles. Post herpetic neuralgia is pain that
persists for weeks or months after shingles lesions heal.
Contagious
Very contagious with secondary attack rates as high as
90%.
PL
E
Agent
Disease risk
Among persons 15-19, the death rate is 2.7:100,000
cases but among adults 30-49 the death rate is
25.2:100,000.
Treatment
Antiviral drugs; supportive care. Immune globulins
(VariZIG or IGIV) may prevent or modify varicella disease
if given soon enough. Administration of varicella vaccine
within 72 hours (and possibly up to 120 hours) after
contact may prevent or cause a less severe case.
SA
M
Possible
complications
Adults have more severe disease and a higher incidence
of complications. Infected skin lesions are the most
common cause of hospitalization and outpatient medical
visits. Pneumonia may follow and is more common
in children. Maternal varicella from 5 days before to
2 days after delivery may result in an overwhelming
infection of the neonate with a death rate as high as
30%. Immunocompromised persons are at high risk of
severe disease that may become hemorrhagic. Other
complications: encephalitis, aseptic meningitis, Reye’s
syndrome, Guillian Barre’ Syndrome, low platelets, kidney
inflammation, heart muscle inflammation, arthritis,
hepatitis.
Varicella
(Chickenpox)
Vaccine(s)
Single antigen, live attenuated vaccine; may be
available in combination as MMRV. Healthcare
personnel need either laboratory evidence of
immunity or 2 valid documented doses.
Appearance
A clear colorless to pale yellow liquid when
reconstituted.
Dose/route
0.5ml SC.
Vaccine risk
Local reactions are reported by 19% of children
and by 24% of adolescents and adults. A
varicella-like rash at the injection site is reported
by 3% of children and 1% of adolescents and
adults after the second dose. A generalized
varicella-like rash is reported after the second
dose by 4%-6% of recipients and by 1% of
adolescents and adults. Severe reactions are very
rare.
Contraindications
Pregnancy or becoming pregnant within 4 weeks
after vaccination, immunosuppression due to
disease or medication.
Precautions
HIV infected children with CD4 T-lymphocyte
percentage >15% and older children and adults
with a CD4 count of >200 per microliter may be
considered for single antigen varicella, but should
not receive MMRV; moderate or severe acute
illness; history of seizures regardless of cause.
Consult a reference for those who have recently
received antibody containing blood products.
False
Contraindications
Receiving low dose alternate day topical,
replacement or aerosolized steroid preparations;
those whose steroid therapy has been
discontinued for 1 month or chemotherapy for 3
months.
Citations:
American Academy of Pediatrics. In Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds.
Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove
Village, IL: American Academy of Pediatrics; 2009
Centers for Disease Control and Prevention. Epidemiology and Prevention of VaccinePreventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed. Washington DC:
Public Health Foundation, 2011.
Disclaimer:
Information in The Greater Risk? Disease vs. Vaccine is current at time of printing.
The most up-to-date information regarding vaccines and vaccine-preventable diseases is
available at http://www.cdc.gov/vaccines/vpd-vac/default.htm.
The Greater Risk?
Disease vs. Vaccine
Snohomish Health District
Vaccine Preventable Disease Community Program
3020 Rucker Avenue, Suite 208
Everett, WA 98201
Published
April, 2012